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Secretary of State Office of Professional Regulation

A supplement to the report submitted March 15, 2019 to the House and Senate Committees on Government Operations, entitled MULTI-STATE NURSING LICENSURE COMPACT: THE COSTS AND BENEFITS FOR VERMONT

In accordance with 2017, No. 144 (Adj. Sess.), § 19, the Office of Professional Regulation was directed to evaluate the costs and benefits of participation in licensure compacts for nurses at various levels of licensure. This supplement reports the findings of a survey from a survey of nurse licensees

as to costs and benefits of compact participation.

November 19, 2019

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In a 2018 report to the General Assembly, the Office of Professional Regulation (OPR) found substantial benefits to participation in the Nurse Licensure Compact (NLC). As an agreement among member-states to enact conforming legislation, the NLC’s compact license offers permeable borders for said states’ licensed practical nurses and registered nurses. However, NLC participation would necessitate an increase in fees. To determine nurse opinion as to these trade-offs, the Office conducted a survey of all actively-licensed nurses. A robust response demonstrated very high interest in Compact participation among nurses, with strong majority support for entry persisting after frank confrontation with associated fees. Nurse employers are nearly unanimous in their support for Compact participation. Because we now have confidence that a substantial majority of the licensee population also supports Compact participation, OPR recommends that the General Assembly implement Compact legislation.

I. Background

Pursuant to Act 144 (2018) § 19, the Office of Professional Regulation submitted to the General Assembly a report entitled Multi-State Nursing Licensure Compact: The Costs and Benefits for Vermont. OPR found that NLC participation would benefit the State by expanding the pool of registered- and practical nurses immediately available for hire by Vermont health care providers, and would reduce red tape and compliance burdens for those nurses, who would be eligible to work under Compact licenses issued by other member states without obtaining a Vermont license. Similarly, Vermont-resident nurses would be eligible to obtain Compact licenses entitling them to work in other member states without obtaining, and paying for, separate licenses in those states—a substantial benefit to those Vermont-resident nurses working in New Hampshire, interested in travel, or engaged in telepractice. However, NLC participation would reduce the number of Vermont-licensed nurses among whom is shared the cost of financing Vermont’s nurse-regulatory program. OPR estimated that this cost-focusing effect would result in an increase in biennial (two-year) license maintenance fees; for Practical Nurses, from $175 to $205; for Registered Nurses, from $190 to $270. With these benefits and costs in mind, OPR recommended that policymakers carefully evaluate preferences of the affected licensee population before moving forward with Compact legislation.

II. The NLC

The National Council of State Boards of Nursing (NCSBN) developed the NLC to allow for mutual recognition of state licenses between the participating states. The NLC streamlines nurse mobility and promotes the standardization of nursing practice regulations (Evans, 2015; Litchfield, 2010; Poe, 2008; Thomas & Thomas, 2018). To further increase access to care and enhance public protection, NCSBN promoted an enhanced NLC (eNLC) in 2015 (Alexander, 2016; Fink, 2018; Fotsch, 2018). The eNLC implemented in January 2018 requires mandatory criminal background checks as well as 10 additional uniform licensure requirements. At this writing, 33 states have passed legislation necessary to implement the NLC (Figure 1). Participation is strongest among southern, central, and mountain states; weakest in the northeast and Pacific-coast states. New Hampshire and Maine are members of the NLC. New Jersey recently passed legislation predicate to implementation. See Appendix B for the Implementation Dates of the current NLC states.

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Figure 1. Current membership of the NLC, sourced from www.ncsbn.org/nurse-licensure-compact

III. Survey Methodology

This was a web survey of all nurses currently licensed in Vermont with valid email addresses registered with the Board of Nursing. OPR designed the survey instrument, consisting of ten questions regarding nurses’ opinions about VT joining the NLC, as well as their demographic, licensure, and practice information (Appendix C). The NCSBN performed the online survey using the Qualtrics platform. The survey was estimated to take less than five minutes to complete.

The study subjects are all nurses who hold an active Licensed Practical Nurse (LPN) or Registered Nurse (RN) license in VT. On July 15, OPR provided NCSBN with an email roster for all 18,351 active nurse licenses (15,104 RNs, and 2,262 LPNs, and 985 APRNs). After de-duplicating and cleaning the mailing list, Qualtrics distributed the survey to 17,083 email addresses.

To help the study subjects better understand the survey purpose and encourage their participation, a study announcement was distributed via email by OPR and the Board of Nursing on July 22, 2019 (Appendix D). NCSBN distributed the Qualtrics survey invitation on July 24, 2019. Three follow-up reminders were sent to non-respondents (Appendix E). The online survey was removed August 10, 2019.

The survey did not collect identifiable personal information such as name or social security number of the participants. The email address was the only link to the individual participant. Only aggregate data were analyzed and reported. OPR cannot link respondents to responses.

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IV. Results

Out of the 17,083 surveys distributed, 222 were bounced back, indicating these surveys did not arrive in the recipient’s inbox due to invalid email addresses or the recipient’s mail server blocked the survey. Five respondents excluded themselves from the survey due to having no nursing license with VT at the time of the survey. Thus a total of 16,856 surveys reached the valid study subjects.

As of August 10, 6,826 surveys were returned. However, the Qualtrics platform allows respondents to skip questions without answering. For example, the most common question left unanswered pertained to income range. Overall, there were 6,641 complete responses (97.3% completion). The adjusted complete response rate is 39.4%. Assuming that non-response is random, at the 95% confidence level, the maximum margin of error for the findings from the current survey is ±1.2%1.

Based on the physical addresses in licensing data, OPR reports that at the time of the survey 8,933 (53%) of Vermont licensed nurses were Vermont Residents. There were 3,993 complete responses from self-reported Vermont residents. Therefore the response rate for the Vermont resident nurse subpopulation is 44.7%, whereas the response rate for the non-resident nurse subpopulation is 34.7%. Assuming that non-response is random, at the 95% confidence level the maximum margin of error for findings from the aforementioned subpopulations is ±1.5% and ±1.8%, respectively.

a. Participant Support for the NLC despite Fee Increase

The primary purpose of this survey was to gauge licensed Vermont nurses’ interest in the NLC. Respondents were able to answer “yes,” “no,” or “no opinion” regarding their support for joining the NLC. The Office of Professional Regulation has estimated that joining the Compact would require an increase in Vermont nurse license fees. This survey asked if respondents are in favor of joining the NLC, both with the necessary fee increase, and more generally (with no fee increase).

Overall, 59% of all Vermont licensed nurses said they were in favor of Vermont joining the NLC despite a fee increase (Figure 2). Additionally, 16% responded that they had no opinion. Taken together, we may say that 75% of all Vermont’s licensed nurses are not opposed to joining the NLC despite a fee increase.

By comparison, 52.8% of Vermont’s resident nurses support joining the NLC with a fee increase. Combined with the 14.5% of resident nurses with no opinion, we may say that 67.3% of resident nurses are not opposed to joining the NLC at the cost of a fee increase (Figure 2).

1 The margin of error (MOE) is given by: MOE = Z* √p* (1-p)/√n

52.78%

68.64%

59.25%

14.52%

17.72%

15.82%

32.70%

13.64%

24.93%

0.00% 20.00% 40.00% 60.00% 80.00% 100.00%

VT Resident

Non-VT Resident

All Licensed Nurses

Yes No Opinion No

Figure 2. Support for NLC with fee increase, by VT resident nurses, non-resident nurses, and all VT licensed nurses combined.

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Non-resident nurse participants were the most supportive of Vermont joining the NLC (68.6%; Figure 2). Combined with the 17.2% of non-resident nurses with no opinion, we may say that 86% of all non-resident nurses licensed in Vermont are not opposed to Vermont joining the NLC. Non-VT resident nurses were distributed in all other 49 states in the United States, including the District of Columbia (Table 1). More than 50% of all non-resident participants are self-reported residents of NLC member states. If Vermont were to join the NLC, these individuals would no longer purchase a Vermont State Nursing License. As such, given the high proportion of traveling nurses from NLC-member states, it is unsurprising that a majority of non-residents are supportive of the NLC. Likewise, the primary explanation from non-residents who are opposed to the NLC with a fee increase, is that they live in non-NLC member States and would be paying an additional amount for their Vermont nursing license without receiving any benefit (as the NLC multi-state license may only be granted to residents of NLC-member states).

Table 1. Distribution of the Top 15 Frequently Reported Jurisdictions Where Non-VT Residents Live (n=2,753)

Jurisdiction Percent

NH* 14.1% NY 11.5% FL* 9.7% TX* 7.3% NC* 6.9% MA 5.3% TN* 3.1% PA 2.8% MO* 2.4% GA* 2.4% CA 2.2% OH 2.2% AZ* 2.1% ME* 2.0% VA* 2.0%

* Compact States

Table 2. Primary Residency in VT County Percent County (Cont’d.) Percent Addison 6.0% Lamoille 3.8% Bennington 5.4% Orange 4.7% Caledonia 5.1% Orleans 3.6% Chittenden 28.0% Rutland 8.7% Essex 0.9% Washington 10.7% Franklin 6.6% Windham 6.8% Grand Isle 1.2% Windsor 8.5%

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Nearly 60% of all survey respondents were Vermont residents (Table 2). Just under 40% of self-reported residents live in Chittenden and Washington counties. Less than 1% of self-reported residents live in Essex County.

The percentage of resident nurse respondents not opposed to joining the NLC (with fee increase) is generally higher along the eastern border counties (Figure 3). While no definitive causal links may be drawn from this survey, this phenomenon may be attributable to New Hampshire’s status as an NLC-member State. If Vermont were to join the NLC, Vermont’s resident nurses could work in New Hampshire without needing to purchase a New Hampshire State Nursing License. Therefore, it is unsurprising that nurses in counties bordering New Hampshire are more interested in Vermont joining the NLC.

Figure 3. Percentage of Vermont resident nurse survey participants not opposed to Vermont joining the NLC for a fee increase, by county. These percentages are a combination of nurses who answered either “Yes” or “No Opinion” to whether or not they supported joining the NLC despite a fee increase.

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There is no strong correlation between self-reported Vermont residents’ age and interest in joining the NLC at the cost of a fee increase (r = 0.34, p < 0.00001; Figure 4).

However there is a strong negative correlation between self-reported Vermont resident nurses’ age and interest in working out of State (r = -0.89, p < 0.00001; Figure 4). In other words, 79% of variability in Vermont resident nurse respondents’ interest in working out of State can be explained by variability in age: younger resident nurses are more likely to want to work out of State.

20-2425-2930-3435-3940-4445-4950-5455-5960-6465-6970-7475-7980-84

No 21 83 130 132 125 124 130 155 191 160 49 6 0

No Opinion 25 32 61 54 45 51 44 66 86 72 34 9 1

Yes 80 155 190 188 209 212 234 246 290 212 69 18 4

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Figure 4. Vermont resident nurses’ support for joining the NLC with fee increase, by age.

Figure 5. Vermont resident nurses’ interest in working out of state, by age.

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%

20-2425-2930-3435-3940-4445-4950-5455-5960-6465-6970-7475-7980-84

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Among all self-reported Vermont resident nurses, RN are the least likely to support joining the NLC for fee increase (Figure 6). See Appendix F for a chart of support by age and credential type.

A Chi-Square test indicates that there is a statistically significant difference in the support for joining NLC for a fee increase, by credential type (X2 = 56.75, p<.00001; Appendix G). However, the measure of effect size is small (Cramer’s V = 0.0843).2 Therefore while adjusted residuals indicate particular and significant differences in credential type preferences, effect size (i.e. “practical significance”) of these differences is low.

b. Participant Support for the NLC without Fee Increase

Support for the NLC generally, i.e. if there were no fee increase, is very high. Overall, 93% of Vermont licensed nurses are in favor of the NLC. When “Yes” and “No Opinion” responses are taken together, we may say that 97.6% of Vermont residents support joining the NLC (Figure 7).

Figure 7. Vermont licensed nurses’ support for the NLC without a fee increase, by residence.

2 Cramer’s V may be calculated with the formula: V = √[X2 / (n * min{r-1, c-1})]

0%

20%

40%

60%

80%

100%

LPN RN APRNYes No Opinion No

Figure 6. Vermont resident nurses’ support for NLC despite fee increase, by credential type.

91.9%

90.6%

92.8%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%100%

Vermont Residents

Non-Vermont Residents

All Licensed Nurses

Vermont Residents Non-Vermont Residents All Licensed NursesYES 3649 2489 6138

No Opinion 192 221 413

No 92 36 128

YES No Opinion No

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c. Reasons for Opposition to NLC Participation

Nurses who responded “No” when asked about their interest in Vermont joining the NLC, both with and without a fee increase, were asked provide their reasoning:

1. Cost of joining the NLC -An $80 increase on hard working nurses is too expensive -The license fee is already too high -Joining the Compact may undermine financial status of the VT BON.3 -Nurses want to work in multiple States should have to pay for that, not everyone else -Vermonters shouldn’t have to pay for out of State nurses’ licenses -Older nurses who work per diem cannot afford the fee increase

2. Concerns on patient safety -Unsafe nurse may practice in VT -Need background check: a nurses with a criminal conviction history in another state may on the run from the law and start another job4 -Training short-term contractors is expensive -Nursing standards in other states are not as high

3. Lack of nursing regulation -Maintain VT BON sovereignty, do not want outside interests influencing VT BON -States should know who is working in their jurisdictions -Each state monitors practice using different criteria -Lack of control over who practices in the state -Difficult to track nurses who were disciplined or fired5

4. Endangering job opportunities -Risk of loss of VT nursing pool -New nurses may leave VT -It will allow job seekers from other state who may not have the best interest of the profession take advantage of employment opportunities -Would wind up with more travel nurses instead of permanent staff, and full time residents would leave the state to travel -Vermont needs more resident nurses -Afraid we would lose more nurses than we receive: nurses are paid more out of State -Don’t like the idea of a majority of travel nurses

3 This perception would be valid if fees were not adjusted to maintain revenue; however, the survey rested upon the premise that fees necessarily would be adjusted. In such a scenario, the Board’s fiscal stability would not be jeopardized. 4 Contrary to the participant’s perception, Compact participation would have the incidental effect of requiring, for the first time, fingerprint-supported, federal criminal background checks of Vermont nursing applicants. No such background checks are conducted under current law. Compact licensees with non-Vermont states of primary licensure would be background checked by those states. 5 See fn. 4, supra.

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5. Lack of interest -Retired or retiring -Have no intention to practice outside of VT -Feel the NLC is unnecessary

6. Lack of knowledge on the NLC - Need more information about the NLC

d. Limitations and Discussion

This study relied upon voluntary self-reported data. Due to the study design, nurses who did not have a valid email account and internet access were excluded from participation. While valid email addresses are a requirement for the biennial license renewal, there is no way of knowing how many nurses in Vermont lack internet access. The analysis of survey results assumes that non-response is random. Yet, it is worth noting that a Chi-Square “goodness of fit” test indicates that the age distribution of Vermont resident nurse respondents is significantly different from the Vermont resident nurse population (X2 = 33, p<0.0001; Table 3). Adjusted standard residuals indicate that the proportion of Vermont resident nurse respondents in their 20’s and 30’s is significantly lower than that of the population. Likewise, the proportion of respondents in their 60’s is significantly higher than that of the population. This means that there may be an over-sampling of resident nurses in their 60’s and an under-sampling of resident nurses between the age of 20 and 50. However, the measure of effect size is low (Cramer’s V = 0.065). Similarly, a Chi-Square test shows that the response rate for Vermont resident nurses is statistically different from that of the overall population, by credential type (X2 = 93.8, p< 0.0001; Appendix H). Yet, the effect size remains low (Cramer’s V = 0.108).

Table 3. Chi-Square “goodness of fit” test comparing the age proportions between resident nurse respondents and resident population age proportions.

Age Range

Survey Frequency

Expected Frequency

Chi-Square Statistic

Adjusted Residuals

20-29 395 460 9.184782609 -3.0306 30-39 754 845 9.8 -3.1305 40-49 759 760 0.001315789 -0.0363 50-59 864 816 2.823529412 1.6803 60-69 981 891 9.090909091 3.0151 70-79 176 157 2.299363057 1.5164

Totals 3929 3929 33.1999

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It is not only possible but reasonable that our respondents are a self-selected group with strong opinions about the NLC, such that we may overestimate both support and opposition and underestimate the size of the “no opinion” group among the VT nursing workforce. There is an important distinction between the nature of this survey and that of purely academic endeavors: this survey was conducted by a governmental regulatory authority to a self-interested group of occupation members. OPR sampled the entire population of licensees for the express purpose of collecting public feedback on potential legislation. Licensees have a professional responsibility to use their occupation-specific expertise to provide feedback to OPR on the future direction of the occupation and any potential legislation therein. Common external survey response rates are between 10% to 15% (Fryrear, 2015). As such, the current survey response rate (39.5%) is high. OPR considers this further evidence that a large proportion of non-responders had no opinion about the survey’s subject matter. Respectfully submitted to the House and Senate Committees on Government Operations; the House Committee on Health Care; and the Senate Committee on Health and Welfare. STATE OF VERMONT SECRETARY OF STATE OFFICE OF PROFESSIONAL REGULATION BY:

November 19, 2019

Dylan Bruce Date Senior Policy Planner

APPROVED:

November 19, 2019

S. Lauren Hibbert Date Director

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REFERENCES

Alexander, M. (2016). Public trust in nusing goes beyond state lines. Journal of Nursing Regulation, 7(2), 3.

Evans, S. (2015). The Nurse Licensure Compact: A historical perspective. Journal of Nursing Regulation, 6(3), 11-16.

Fink, J. L. W. (2018). Many states, one licensure: The enhanced nursing nurse licensure compact is now live. Retrieved from https://campaignforaction.org/many-states-one-license-enhanced-nurse-licensure-compact-now-live/

Fotsch, R. (2018). The enhanced Nurse Licensure Compact goes live. Journal of Nursing Regulation, 8(4), 61-62.

Fryrear, A. (2015). What's a Good Survey Response Rate? Retrieved from https://www.surveygizmo.com/resources/blog/survey-response-rates/

Litchfield, S. M. (2010). Update on the nurse licensure compact. AAOHN J, 58(7), 277-279. doi:10.3928/08910162-20100625-03

Poe, L. (2008). Nursing regulation, the nurse licensure compact, and nurse administrators: working together for patient safety. Nurs Adm Q, 32(4), 267-272. doi:10.1097/01.NAQ.0000336722.10689.d3

Thomas, K. A., & Thomas, M. B. (2018). The Texas Board of Nursing responds to disaster. Journal of Nursing Regulation, 9(2), 41-46.

Vermont Secretary of the State OPR. (2019). Multi-state Nursing Licensure Compact: The costs and benefits for Vermont. Retrieved from https://legislature.vermont.gov/assets/Legislative-Reports/Act-144-Nurse-Compact-Report.pdf

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APPENDIX A: CALCULATING THE COST OF THE eNLC The following is adapted from the original report, filed in accordance with 2017, No. 144 (Adj. Sess.), § 19, MULTI-STATE NURSING LICENSURE COMPACT: THE COSTS AND BENEFITS FOR VERMONT (pages 6-8). Fees and total impact updated to those passed in 2019, No. 70, § 13.

The eNLC in Vermont: Potential Costs There are more nurses working in Vermont from other Compact States than Vermont resident nurses working in other Compact States. Upon Compact implementation, 4,705 Vermont licensees (about 25% of the total number of Vermont nurse licensees) would cease to contribute to the fixed costs of the State’s nurse-regulatory program.

Figure 4: Vermont’s estimated loss of licensure secondary to NLC participation. With fewer licensees contributing to the regulatory fund, there will be a significant and ongoing loss of Board revenue.6 This phenomenon would diminish revenue by approximately $888,895 (Figure 5), against a total budget of approximately $4,000,000 per biennium.

Figure 5: The loss of licensing revenue as a result of joining the eNLC.

Profession Type NLC Net Licensure Impact

Registered Nurse (RN) -4,368

Practical Nurse (PN) -337

Total -4,705

Profession Type eNLC Net Licensure Impact eNLC Financial Impact

Registered Nurse (RN) -4,368 -$829,920.00

Practical Nurse (PN) -337 -$58,975.00

Totals -4,705 -$888,895.00

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The Compact Administration recommends that member states charge equal fees for single-state licenses and Compact licenses. Fee increases necessary to offset Compact-related revenue loss, thereby maintaining a positive Board of Nursing fund balance, are illustrated in Figure 6.

Profession Type Current Renewal

Fee Proposed Renewal

Fee

Renewal Fee Needed to balance funds with NLC Participation7

Registered Nurse $140.00 $190.00 $270

Practical Nurse $140.00 $175.00 $245

Figure 6: The estimated fee increases for Vermont-only licensees necessary to account for joining the eNLC.

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APPENDIX B: CURRENT COMPACT STATES

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APPENDIX C: 2019 VT NURSE LICENSURE COMPACT SURVEY INSTRUMENT

Introduction: The Vermont Secretary of State's Office of Professional Regulation is seeking your input on the Nurse Licensure Compact. The Compact allows a nurse who holds one multi-state license issued by a Compact state to practice in any other Compact state without obtaining additional licenses. There are 31 states in the Compact, including New Hampshire and Maine. The Compact facilitates cross-border practice and allows a nurse to move freely among Compact states without obtaining a license from each. The Vermont Board of Nursing is frequently asked, “Will Vermont join the NLC?” To help us better understand Vermont nurses' opinions of the Compact, please answer the following questions. This survey has been distributed by the National Council of State Boards of Nursing on behalf of OPR and the Vermont State Board of Nursing. Your voice matters. Thank you in advance for setting aside a moment to make your input known.

Q1. What type of license do you currently hold? (Select all that apply.)

� LPN � RN � APRN

Q2. What is your age range?

� <20 � 20-24 � 25-29 � 30-34 � 35-39 � 40-44 � 45-49 � 50-54 � 55-59 � 60-64 � 65-69 � 70-74 � 75-79 � 80-84 � 85-89 � ≥90

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Q3. Is Vermont your primary state of residence? Yes In which Vermont county do you live?

o Addison o Bennington o Caledonia o Chittenden o Essex o Franklin o Grand Isle o Lamoille o Orange o Orleans o Rutland o Washington o Windham o Windsor

� No Which state/jurisdiction is your primary residence? o AK o AL o AR o AZ o CA o CO o CT o DC

o DE o FL o GA o HI o IA o ID o IL o IN

o KS o KY o LA o MA o MD o ME o MI o MN

o MO o MS o MT o NC o ND o NE o NH o NJ

o NM o NV o NY o OH o OK o OR o PA o RI

o SC o SD o TN o TX o UT o VA o WA o WI

o WV o WY

Q4. Do you hold an active nursing license in a state other than Vermont?

� Yes � No

Q5. In the past 24 months, have you been employed in a position that required a nursing license?

� Yes � No

Q6. For how many separate nursing employers do you normally work?

� 0 � 1 � 2 � 3 or more

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Q7. What is your (total) gross personal annual income? $20,000 - $29,000 $30,000 - $39,000 $40,000 - $49,000 $50,000 - $59,000 $60,000 - $69,000 $70,000 - $79,000 $80,000 - $89,000 $90,000 - $99,000 $100,000 - $109,000 $110,000 - $119,000 $120,000 - $129,000 $130,000 - $139,000 $140,000 - $149,000 ≥ $150,000

A Compact license is issued by a nurse's state of permanent residence. If Vermont were to join the Compact, a Vermont-resident nurse could work in any of the 31 other Compact states without a separate license from each. When a nurse changes his or her permanent state of residence, he or she must apply for a Compact license from the new state of residence. For example, if a Vermont resident nurse moves to New Hampshire (another NLC-member state), the nurse must apply for licensure with New Hampshire's Board of Nursing. Likewise, a nurse who moves permanently from a Compact state to a non-Compact state is no longer eligible to hold a Compact license.

Q8. If Vermont were to join the Nurse Licensure Compact, would you now or in the future have an interest in working out of State?

� Yes � No

Q9. The Office of Professional Regulation has estimated that joining the Compact would increase Vermont license fees. For Practical Nurses, the biennial (two-year) license renewal fee would increase from $175 to $205. For Registered Nurses, it would increase from $190 to $270. Would you be in favor of Vermont joining the Compact if licensing fees increased accordingly?

� Yes � No (please provide reason) ____________________ � No opinion

Q10. If it were possible to join the Compact without a fee increase, would you be in favor of Vermont becoming a Compact state?

� Yes � No (please provide reason) ____________________ � No opinion

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APPENDIX D: STUDY ANNOUNCEMENT

Dear Vermont Nurses, The Office of Professional Regulation (OPR) is seeking your input on the Nurse Licensure Compact (NLC). You will be contacted via email by the National Council of State Boards of Nursing (NCSBN) this week to take part in a brief survey created by the Vermont Board Nursing, in collaboration with NCSBN, regarding the NLC. Healthcare today is fluid and crosses state lines. Many nurses care for patients located in a state that is different from their home state. The NLC is a viable solution to facilitate the mobility of nursing services and access to care. Facts about the NLC: • Must be enacted by the Vermont legislature. • Has been in effect in the nation for nearly 20 years. • Has been enacted by 33 states. • Facilitates cross-border practice both physically and electronically (telehealth, online education).

• Allows nurses who hold a multistate license issued by their home Compact state to practice in any other Compact state using a single license.

• Requires the nurse to practice according to the Nurse Practice Act in the state where the patient is located.

• Does not supersede existing state labor laws. The Vermont Board of Nursing receives numerous inquiries as to whether Vermont will join the NLC. In March of this year, the Board submitted a joint report with OPR to the state legislature on the costs and benefits of the NLC for Vermont. To read the full report click here. Thank you in advance for sharing your thoughts about the NLC by participating in the survey once you receive it. Your voice matters and we appreciate your input. Sincerely, Lauren Hibbert Director, OPR & Phyllis Mitchell Executive Officer of Vermont State Board of Nursing, OPR

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APPENDIX E: COVER LETTERS Initial Qualtrics Survey Invitation Dear Colleague, Recently you received an email from Lauren Hibbert, OPR Director and Phyllis Mitchell, Vermont Board of Nursing Executive Officer, regarding a survey about the Nurse Licensure Compact (NLC). I am writing to follow up on that request for your input on this important issue. On behalf of the Vermont Secretary of State’s Office of Professional Regulation and the VT BON, the National Council of State Boards of Nursing (NCSBN) is conducting this NLC survey. It will take less than five minutes of your time to fill out the survey. Your responses will assist the VT BON in making decisions regarding adoption of the NLC in Vermont. Please click here to take the survey: Participation in the survey is voluntary. Your responses will be completely confidential and only aggregated data will be examined and reported. If you have any questions or comments about this survey, please contact me via email (ezhong@ncsbn.org). Thank you very much for helping with this important study. Sincerely, Elizabeth Zhong, PhD National Council of State Boards of Nursing ezhong@ncsbn.org Follow-up Reminder We need your help. In the past week you should have received an invitation to take a short survey about the Nurse Licensure Compact (NLC) from the National Council of State Boards of Nursing. If you have already completed this survey, we sincerely thank you for your participation! If you have not yet completed the survey, please take a few minutes to share your opinions about Vermont joining the NLC. The survey will close on 8/9/2019 and we want to be sure we have included your opinion. Follow this link to the Survey: If you have any questions or comments about this study, please feel free to contact Elizabeth Zhong, PhD, NCSBN (ezhong@ncsbn.org), who is conducting the survey on our behalf. Sincerely, Lauren Hibbert, OPR Director Phyllis Mitchell Executive Officer Vermont Board of Nursing

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APPENDIX F: VERMONT RESIDENT NURSE SUPPORT FOR JOINING THE NLC DESPITE FEE INCREASE, BY AGE & CREDENTIAL TYPE & INCOME

$0.00 $20,000.00 $40,000.00 $60,000.00 $80,000.00$100,000.00$120,000.00

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

LPN RN APRN

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%

20-2425-2930-3435-3940-4445-4950-5455-5960-6465-6970-7475-7980-84

LPN RN APRN

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APPENDIX G: CHI-SQUARE TEST FOR VERMONT RESIDENT NURSE SUPPORT FOR JOINING THE NLC DESPITE A FEE INCREASE, BY CREDENTIAL TYPE

Q3 + Q9

Vermont Resident? Yes Yes Yes

Join NLC for Fee Increase? Yes No Opinion No

Observed Frequencies

LPN 237 79 94

RN 1625 442 1132

APRN 246 59 80

Expected Frequencies

LPN 216.3946 59.53930896 134.0660991

RN 1688.406 464.5518277 1046.042564

APRN 203.1998 55.90886329 125.891337

Chi-Square Statistic

LPN 1.962077 6.36081443 11.97388685

RN 2.381105 1.094786209 7.063460977

APRN 9.015054 0.170905391 16.72883029

Adjusted Standard Residuals

LPN 2.15185 2.879709403 -4.452736573

RN -5.0332 -2.536631591 7.261371212

APRN 4.59651 0.470392883 -5.244846412

Chi-Square = 56.751, p<0.00001

Cramer’s V = 0.0843

23

APPENDIX H: CHI-SQUARE TEST FOR VERMONT RESIDENT NURSE RESPODENT CREDENTIAL DISTRIBUTION

A chi-square goodness of fit test shows that the difference between the self-reported Vermont resident credential distribution and that of the population is statistically significant (X2 = 93.8, p < 0.0001). Standard Pearson residuals suggest that while the proportion of RN respondents is not significantly different from expected, the proportion of LPN is significantly smaller and APRN significantly greater, than that of the population.

Observed (survey)

Observed Proportion

Population Proportion

Expected Chi-Square

Pearson Residuals

LPN 410 0.1027 0.1485 593 56.474 -7.52

RN 3198 0.8010 0.7800 3115 2.212 1.49

APRN 385 0.0964 0.0714 285 35.088 5.92

Totals 3993 1 1 3993 93.773

Cramer’s V = 0.108, indicating that while the difference is statistically significant, the effect size (magnitude, i.e. practical significance) is low.